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1 : Blue Option / Gold 800 Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $800 Individual / $1,500 Family for innetwork. Doesn t apply to preventive care. Copays do not accumulate towards deductible. No Yes. $3,500 Individual / $6,700 Family for in-network. Premiums, balance-billed charges, and health care this plan doesn t cover. Yes. For a list of participating providers see or call No. You don t need a referral to see a specialist. Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. 1 of 8

2 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.). This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Your cost if you use an In-Network Out-of- Network Limitations & Exceptions Primary care visit to treat an injury or illness $20 co-pay / visit Not Covered none Specialist visit $50 co-pay / visit Not Covered none Other practitioner office visit $20 co-pay / visit Not Covered none Preventive care/screening/immunization $0 Not Covered none Diagnostic test (x-ray, blood work) co-insurance Not Covered none Imaging (CT/PET scans, MRIs) co-insurance Not Covered none Generic drugs $10 co-pay retail Not Covered Covers up to a 31-day supply retail Preferred brand drugs $35 co-pay retail Not Covered prescription. You will have to pay more if you select a brand-name drug Non-preferred brand drugs co-insurance Not Covered instead of a generic drug. Certain prescriptions may require prior authorization or have dosage limits. Specialty drugs Covers up to a 31-day supply for Oral $250, then prescription. Certain prescriptions deductible, then Not Covered may require prior authorization or have dosage limits. 2 of 8

4 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your cost if you use an In-Network Out-of- Network Home health care co-insurance Not Covered Rehabilitation services co-insurance Not Covered Habilitation services co-insurance Not Covered Skilled nursing care deductible, then Not Covered Durable medical equipment co-insurance Not Covered Hospice service co-insurance Not Covered Eye exam $25 Not Covered Glasses $50 Not Covered Dental check-up Balance over $27 for 1st visit and balance over $20 for periodic Balance over $27 for 1st visit and balance over $20 for periodic Limitations & Exceptions Prior authorization required 60 visits per Benefit Period 30 combined visits per Benefit Period for occupational therapy, physical therapy, speech therapy and habilitation 30 combined visits per Benefit Period for occupational therapy, physical therapy, speech therapy and habilitation Prior authorization required 60 days per Benefit Period Prior Authorization required Up to purchase price Prior authorization required 6 months per episode One comprehensive exam every Benefit Period. Refer to your plan document for a full list of limits/exceptions. One pair from a designated selection every Benefit Period. Refer to your plan document for a full list of limits/exceptions. No network limitations 4 of 8

5 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Chiropractic Care Cosmetic surgery Hearing Aids Infertility treatment Long-term care Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Dental care (Adult) Non-emergency care when traveling outside the U.S. Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a compliant or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact BlueChoice HealthPlan at or visit the U.S. Department of Labor, Employee Benefits Security Administration at or or the South Carolina Department of Insurance, Consumer Services Division, Post Office Box , Columbia, SC , telephone: , Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. 5 of 8

6 Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: To obtain assistance in your specific language, call the customer service number shown on the first page of this notice. Spanish (Español): Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,172 Patient pays $1,368 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $800 Co-pays $365 Co-insurance $53 Limits or exclusions $150 Total $1,368 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,821 Patient pays $1,579 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $800 Co-pays $370 Co-insurance $330 Limits or exclusions $79 Total $1,579 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or pre-existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. 8 of 8

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